What a $7,901 circumcision really means

I hope that everybody saw the article about the family that asked the price of a circumcision at CHC, was quoted $250, couldn’t do it because no physician was available for a few months, and then did it and discovered that the charge was almost $8,000. CHC did in fact raise its rates recently for some services by about 4,000 percent. Now if Saipan was inhabited by Microsoft millionaires, this might be a sustainable economic practice, but the demographics of the island make rate changes like this unlikely to work.

What needs to happen in the CNMI is a real dialogue with the government and community about health care. This dialogue wasn’t happening while I was there, and I doubt it is happening now. Part of the reason why I didn’t more loudly bring it up while I was there was fear: Bringing up problems with the current system sounds like criticism, and I’ve noticed criticism is often not tolerated by those in power. People who managed to stay on Saipan for years had one bit of universal advice: Keep your head down, don’t be noticed. I suspect that many people still feel this way, and that makes an honest public dialogue problematic, but it should happen anyway.

Here are the questions that need to be answered, preferably in public meetings with all of the stakeholders fully participating: How are we going to pay for health care on Saipan? Do we really expect that the indigent are going to be able to afford the rates that we now plan on charging them? Does the 50 percent discount that they get, after a 4000 percent rate increase, really seem that humane? Health care can’t be free, but how much can we expect people who don’t have refrigerators and who walk to CHC from Kagman to really pay? What can we do to prevent abuse of the system? How about the patients who can afford to pay, have private health insurance but also use Medicaid because they don’t want to have a co-pay? Do they understand that not invoking their private insurance helps bankrupt the hospital? What about abuse of the system from powerful people from within? What about native doctors who get paid two salaries at once, retire on the higher income, and then work again for the hospital without even taking overnight call? Can the CNMI really afford a quarter million dollars a year in public funds for this? No wonder we’re asking poor folks to pay $8,000 for what used to be a $250 procedure. No wonder the Retirement Fund now says it is in trouble. How else are those who control the purse-strings benefiting from that power? What about abuse from the Northern Islands? How often do we spend thousands of dollars to bring a kid and his mom back from some remote place because we’re told the kid is on death’s door, and yet he walks happily out of the emergency room half an hour after arrival, sucking a popsicle and just in time to start the fall term of school, just like his emergency evacuation the year before. Maybe the real diagnosis was anticipated seasickness? Can the CNMI keep affording this? And what should we do about it? Remembering the boy who cried wolf, maybe next time the kid will be on death’s door. Why aren’t the physicians who actually provide the care more involved in decisions about how the money is spent in the hospital? Is it because we would spend the money to make sure that there are reagents in the lab and blood in the blood bank and appropriate supplies? Maybe it is because few doctors stay more than a couple of years and there is a general distrust of people off island who haven’t been around for very long. One might ask, why don’t doctors stay? What kind of help can we get from the feds? Every year there are children that die in the CNMI who would have lived if they had the chance to get care at a place with more resources. Dying children evoke sympathy, and maybe a few stories of the realities of practicing medicine in the CNMI along with a plea for help might lead to some more help. Right now Federalization seems limited to fixing problems with CNMI immigration, but wouldn’t it be wonderful if the feds would take over CHC? How have we managed to keep Medicare accreditation, and what will happen when we lose it and lose millions of dollars of health care funding because our hospital cannot meet basic important standards? How much money does the CNMI owe to hospitals in Hawaii, California, Japan and the Philippines, and can we ever pay it? How does being a debtor to these referral institutions change our relationship with them when we have critically ill patients who need to be emergently transferred? Should we just let those patients die, because we cannot afford the care? And if we should, is that a physician decision, an administrator decision, or something that will just happen because of a lack of an accepting hospital, the lack of a way to transfer, and a number of burned bridges? To the point: what should the public policy be when we get a 26 week gestation, 650 gram premee, who has a good chance at life if she’s at a place with more resources, but who will probably cost $1,000,000 that the CNMI doesn’t have? And if it is your personal opinion that we should just let those kids die, would you please be willing to be the one who turns off the ventilator?

Figuring out the funding for healthcare in the CNMI is a huge problem, and there is no easy answer. Cleaning up some abuse might help, but it won’t fix a system that tries to deliver care that it cannot afford to give. Let’s see this desperate move of trying to get more money out of the poor by raising rates by 4000 percent for what it is: a cry for help in a system that is sinking. The whole CNMI needs to wake up and deal with this critically important issue. Lives depend on it.